1. ZOSTAVAX
When not to vaccinate

2. Herpes Zoster
Herpes Zoster (shingles) is a reactivation of the varicella zoster infection in some-one who has previously had varicella(chicken pox) disease
Painful, unilateral, self-limiting vesicular rash in a dermatomal distribution
May have systemic symptoms such as headaches and malaise
Pain may precede the rash

4. Who is at risk?
20-30% of people will develop shingles in the lifetime most are over 50
95% of the population over 30 have had varicella as a child and therefore at risk
Increases with age
Increased in immunosuppressed
Post herpetic Neuralgia PHN highest over 70

5. Zoster Vaccine
Zostavax (MSD) has been registered in Australia since 2006 for adults over 50
Live vaccine – 14x that of chicken pox vaccine
Efficacy declines with age
Protection for PHN is the same for those as for some-one in 60s
If vaccinated may still develop shingles but less severe
At this time boosters not advised

6. Who should be vaccinated?
Zostavax funded for adults age 70 with a catch up 71-79
50-69 private script cost approx. $200
Over 79 private script though efficacy diminished
RPBS will fund via Authority system (also DTPa)
Those over 50 with chronic conditions – private script
Household contacts of immunocompromised- private script

7. Who should not be vaccinated?
Immunocompromised patients
Pregnant women
Anaphylaxis to the vaccine or components(inc gelatin or neomycin)

8. Primary or Acquired immunodeficiency
Haematological Neoplasm:leukaemias, lymphomas, myelodysplastic syndromes
Post-transplant solid organ(on immunosuppressive therapy) haematopoietic stem cell transplant (within 24 months)
Immunocompromised due to primary or acquired(HIV/AIDS) immunodeficiency
Other significant immunocompromising conditions

9. Immunosuppressive therapy(current or recent)
Chemotherapy or Radiotherapy
Corticosteroids(short-term high dose, longer term lower dose)
All biologics and most disease-modifying ant-rheumatic drugs(DMARDs)

10. warning
Some elderly patients are regularly taking corticosteroids and/or DMARDs
This can include patients with RA, IBD, skin conditions, renal disease, MS and other autoimmune conditions .
A detailed medication history is needed before vaccination – a number of these drugs are prescribed by the specialist and may not be recorded in the medication list

11. Mechanism of action Examples* Safe dose**
Anti-TNF Etanercept NONE
Infliximab
Adalimumab
IL-1 inhibition Anakinra NONE
Costimulation blockade Abatacept NONE
B-cell depletion/inhibition Rituximab NONE
Vaccinate 1 month before treatment initiation OR 12 months after treatment cessation

12. Mechanism of action Examples* Safe dose**
Immunomodulators (antimetabolites) Azathioprine ≤3.0 mg/kg/day
6-Mercaptopurine ≤1.5 mg/kg/day
Methotrexate ≤0.4 mg/kg/week
Corticosteroids Prednisone <20 mg/day for <14 days
If on higher dose, vaccinate 1 month before treatment initiation OR 3 months after treatment cessation

13. Mechanism of action Examples* Safe dose**
T-cell activation/inhibition Tacrolimus NONE
Cyclosporine NONE
Others Cyclophosphamide NONE
Mycophenolate NONE
Sulfasalazine NONE
Vaccinate 1 month before treatment initiation OR 3 months after treatment cessation

14. NOTE: This is not a complete list of all licensed biologics, or medications within each class, but serves as a guide only. ** Refer to The Australian Immunisation Handbook 10th edition, Chapters and 4.24.
Also always check the product information of the drug that you are concerned about

15. Patients on Low Dose Steroids and DMARDs
Potentially but only if each drug is not a contraindication e.g. Prednisolone and MTX
Consultation with the treating specialist or immunisation expert is recommended

16. HIV positive patients Asymptomatic HIV not AIDS CD4+ counts>200
Serological proof of previous VZV infection prior to vaccination

17. How long after vaccination before starting immune modulating therapy?
At least 1 month though in extenuating circumstances on a case by case 14 days could be considered safe but I would consult with the specialist involved

18. How long after chemotherapy or radiotherapy?
At least 6 months after the end of treatment and after patients are demonstrated to be in remission

19. What if my patient has had shingles?
Vaccination is safe but recommended to wait for at least 1 year preferably 3 as the episode itself boosts immunity

20. DO I need to check VZV serology ?
No unless special circumstances (HIV, pre-transplant)
Studies show well tolerated and immunogenic in VZV- seronegative adults.
Acceptable to give if seronegative but 2 doses of varicella vaccine is the recommended alternative in a VZV – seronegative adult eligible for zoster vaccine

21. . Can be given with other vaccinations such as pneumococcal
Separate from other live vaccines for 4 weeks if not on same day
Single dose – at this stage boosters not recommended – some studies on boosters at 10 years
Systemic antivirals may decrease vaccine effectiveness. Where possible antivirals should be stopped for 48 hours before vaccination and withheld for at least 14 days

22. warning
If you have assessed as not eligible record this somewhere clearly so that some-one else does not vaccinate
This could include in warnings
Could be in immunised as refused on medical grounds

23. What if an immunocompromised patient receives zoster vaccination?
Seek immediate specialist advice to determine if severely immunocompromised
Will need close monitoring for adverse effects related to the vaccine virus associated disease
May require antiviral therapy

24. Additional resources for primary medical care/vaccination providers
The Australian Immunisation Handbook, 10th edition – the most up-to-date clinical recommendations are contained in the online version of the Handbook home
Immunise Australia website
For more detailed information and complete reference list see the NCIRS factsheet Zoster vaccine for Australian adults: information for immunisation providers